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Microsoft word - pediatric intake questionnaire-2 to 12.doc

Name: _______________________________Age: _________D.O.B.: ________________________Today’s Date:______________________


1.) What is the purpose of your visit…what can I do that would help your child the most? ____________________________________________________________________________________________________________________________________________________________________________________________________________ 2.) Please observe your child and provide general answers to the following. Please circle your answer: In general, are your child’s eyes normally bright Y/N? Is he/she alert and focused or easily agitated? Irritable? Are there dark circles under his/her eyes (not due to lack of sleep)? Y/N? Is the skin plump and smooth or dry, scaly? Are there any rashes, inflammatory issues of the skin, cracks, etc.? If you have any other comments, please list below: ______________________________________________________________________________________________________________________________________________________________________________________________________ 3.) Has your child been “diagnosed” with a medical or psychological condition by a specialist, medical doctor, or other doctor? ___________________________________________________________________________________________________
4.) If you answered yes above, what is his/her prognosis?_______________________________________________________
5.) How often does he/she go to the specialist(s)?______________________________________________________________
Please list specialists, doctors, other contact information (including phone #’s) on a separate page, if required.

6.) If you have you tried any of the following, please list below. Be as specific as possible:
Reaction – positive/negative/no difference…give details


7.) Immunizations (note below, or attach copy of immunization record): VACCINE AGE
8.) Mother: did you have any immunizations as a teenager, young adult, pregnant or nursing mother? If yes, please list: ________________________________________________________________________________________________ 9.) List any complications during pregnancy, delivery or early weeks of your child’s life that concerned you or your doctor: _________________________________________________________________________________________________ Gestational age at birth:_______________________ 10.) How many ultra-sounds did you have?______________ Did you ever take fertility drugs or CLOMID?________________ 2006, by Wellness Wizards Limited, PEDIATRIC INTAKE QUESTIONNAIRE-2 to 12 Name: _______________________________Age: _________D.O.B.: ________________________Today’s Date:______________________
11.) Did you breastfeed?______For how long?_____ What did you give your child after or along with the breastmilk?________
___________________________________________________________________________________________________ 12.) How did he/she react to the breastmilk?______, formula?____________, cow’s milk?______________________________ 13.) At which age, and in what order did you introduce solid foods? Provide as many details as you can remember: __________________________________________________________________________________________________ _________________________________________________________________________________________ ________ 14.) Did your child suffer from colic?__________________________________Coping methods: _________________________ 15.) Please circle if any of the following apply… list others if applicable: Family History of: Multiple Sclerosis, Type I diabetes, Lupus, Rheumatoid Arthritis, Crohn’s Disease, AIDS, Fibromyalgia or
Chronic Fatigue Syndrome, neurological problems, mental illness, heart disease, cancer, allergies, diabetes, intestinal
diseases or problems. Comments:_______________________________________________________________________

16.) Family history of learning disorders, (ADD/ADHD, ASD, PDD, Dyslexia, Down’s Syndrome, Schizophrenia)?__________
17.) Has your child had any ear infections?______ List how many & age?___________________________________________
18.) Was the treatment (for ear infections) the same each time, and how did he/she react?
______________________________________________________________________________________________________________________________________________________________________________________________________ 19.) Has your child had, or do they presently have any infections or illnesses?________________________________________ 20.) If your child has a re-curing infection of the same type, list social or dietary factors that seem to occur at the same time: _______________________________________________________________________________________________

Please fill out a DIET DAIRY for 7 days. Record what/how much your child eats & drinks, comments, reactions & moods.
Pay particular attention to your child’s reactions to foods (behavior, bowel habits, etc.) while doing this diet diary.

21.) Are there any known food allergies or intolerances?______________________________________________________
22.) Describe your child’s appetite:_______________________________Number of meals/snacks per day:________________
23.) Does your child have favourite foods?__________________ How often does he/she eat them?_______________________
24.) Does your child have cravings?________ If yes, which foods? When is the food consumed?_________________________
25.) Are there foods your child absolutely refuses to eat?_________________________________________________________
26.) Are you concerned about your child eating too much? Too little? Developing poor eating habits? Circle if applicable.
27.) Please circle the following if they apply: Difficulties digesting any foods – pain, cramping, screaming, headaches, gas,
bad breath, diarrhea, constipation? Does he/she experience: Alternating diarrhea/constipation, straining to move bowels? Are any of the above situations related to particular foods or circumstances (such as emotional upset, etc?)

28.) Stools – formed, colour?______, foul-smelling, frothy or floating/greasy? Are there pieces of undigested food?___________
Other comments relating to bowel movements: _____________________________________ Number BM/day:__________
29.) Is your child toilet-trained?_____ Does he/she have accidents? ______Bed-wetting?_______________________________

2006, by Wellness Wizards Limited, PEDIATRIC INTAKE QUESTIONNAIRE-2 to 12 Name: _______________________________Age: _________D.O.B.: ________________________Today’s Date:______________________

30.) At what age did your child begin to speak?______point?______
31.) Did you notice that your child began to regress in any of the above, or in other areas, and if so at what age?___________
_________________________________________________________________________________________________ 32.) How long is your child’s attention span (approximately?)_____________________________________________________
33.) Does your child sleep through the night?________________________ Is he/she well/rested?________________________
34.) Comments from teachers, behavioural therapists, on your child’s progress since diagnosis:__________________________
Is your child: aggressive? _____________________Intolerant to heat &/or sunlight?_______________________________
Is your child stressed?________________________Does he/she participate in sports/play groups?___________________
What does he/she like to do for fun?__________________________________________Is he/she happy?______________
How much exercise does your child get?________________ Hours spent watching T.V./video games/day ______________
35.) How does your child interact in a group environment…with children?___________________________________________
…with other adults?__________________________________________________________________________________
36.) Is your child generally happy?
37.) Please list any additional comments, concerns or questions that you may have:


Your name:____________________________ Address: ________________________________________________________
Relationship to child:_____________________________________________________
Contact information: Daytime:__________________________Evening:_________________E-mail:______________________
Disclaimer: Please note that your personal information will be kept strictly confidential. Please see our privacy policy for further
details at: www.wellnesswizards.net. The information and recommendations which you will receive from Wellness Wizards is
meant for procuring and attaining health and well-being for your child and not to diagnose, treat or cure any condition. If your
child has a serious medical condition, please see your medical health professional.
Signature:_____________________________________________________________ Date:____________________________
FAX completed forms to: 905-257-3979 or
MAIL to: Wellness Wizards Limited, P.O. Box 478 Dundas St. West, Oakville, ON. L6Y 6Y0
We cannot guarantee that our office is 100% nut-free.
Please notify us ahead of time if you have any severe or life-threatening allergies.
We will do our best to accommodate your needs. Please call us at: 416-948-9355 if you have any questions.
Thank you for choosing Wellness Wizards.
2006, by Wellness Wizards Limited, PEDIATRIC INTAKE QUESTIONNAIRE-2 to 12

Source: http://wellnesswizards.com/downloads/PEDIATRIC%20INTAKE%20QUESTIONNAIRE-2%20to%2012.pdf


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